Provider Demographics
NPI:1023570223
Name:MATX ANESTHESIA, LLC
Entity Type:Organization
Organization Name:MATX ANESTHESIA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:K
Authorized Official - Last Name:NICKELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-623-6699
Mailing Address - Street 1:1090 EXPERIMENT STATION RD UNIT 529
Mailing Address - Street 2:
Mailing Address - City:WATKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30677-5378
Mailing Address - Country:US
Mailing Address - Phone:800-208-6014
Mailing Address - Fax:706-850-7733
Practice Address - Street 1:800 QUAIL CREEK DR
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79124-1634
Practice Address - Country:US
Practice Address - Phone:800-208-6014
Practice Address - Fax:706-850-7733
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-05
Last Update Date:2019-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty